Trick or Treatment

Trick or Treatment: The Undeniable Facts About Alternative Medicine applies the methodology of double-blind, randomized clinical trials to a number of different forms of ‘alternative medicine.’ Written by Simon Singh and Edzard Ernst, the book describes the history of clinical trials and evidence based medicine: citing historical examples such as finding the cause of scurvy, evaluating bloodletting as a treatment, and the importance of hygiene in hospitals, as empirically and statistically demonstrated by Florence Nightingale.

The bulk of the book consists of an examination of four very common forms of alternative medicine: looking at the clinical trials that have been carried out on them, as well as meta-analyses and systemic reviews that evaluated the quality of those studies and their conclusions. In general, the determinations made about the treatments are not very positive:

Some evidence suggests that accupuncture can be effective for treating pain and nausea, though higher quality studies have generally found less evidence than more problematic ones. No evidence was found that accupuncture treated any other condition, despite how practitioners have advertised it as a cure for many maladies

Homeopathy was shown to be no better than a placebo at treating any illness. This is really no surprise, since the philosophy behind it is bunk and the ‘medicines’ are demonstrably just water.

Chiropractic therapy was shown to have comparable effectiveness to conventional physiotherapy in treating back pain, though with significant risks that do not exist for the latter treatment. Specifically, the ‘high velocity low amplitude’ manipulations used can tear blood vessels in the spine, causing strokes and infarctions.

Some herbal remedies were shown to be effective (such as Saint John’s wart for mild to moderate depression). That being said, much evidence was uncovered of ineffective treatments (including many of the most common), contaminated medications, lax oversight, and possible adverse interactions with pharmaceuticals, when people do not inform their doctors about herbal supplements they are taking.

Perhaps most disturbing of all is the evidence of very poor medical advice provided by alternative care practitioners. All homeopaths surveyed suggested (completely ineffective) homeopathic remedies to protect against malaria during an extended trip through Africa. Chiropracters were willing to perform adjustments on the delicate and developing spines of children and infants, as well as perform adjustments without warning or notice about the significant risk of damage to blood vessels in the spine. Alternative practitioners of all stripes advised parents to avoid using highly effective vaccines on their children, and sometimes told people to discontinue conventional therapies for diseases as serious as cancer and AIDS, leading to suffering or death.

The book also covers a number of critical related topics, including the placebo effect, regression to the mean, the reasons for which large numbers of people (and doctors) have faith in alternative therapies, and issues about medical ethics. In an annex, the authors provide more concise summaries of the research done on many other treatments: ranging from reiki to meditation to yoga. Some are deemed effective, others harmless placebos, while some are identified as dangerous.

I definitely hope this book gets a great deal of public attention. Many of the abuses described are very serious. Unfortunately, the people who would probably benefit most from the book are those who are least likely to accept its analysis and conclusions. The logic of the double-blind, controlled, randomized clinical trial is extremely powerful. Most impressively, it produces unbiased results, even when the thing being tested is not fully understood. For instance, fresh fruit was identified as a cure for scurvy long before the mechanism of action was known. If alternative therapies were as effective as claimed, that would show up readily in the thousands of high-quality trials that have been conducted. The patchy nature of positive results, and the slew of negative ones, thus speak volumes about the relative effectiveness of conventional and alternative therapies.

Thanks for the review, I must read this book… unfortunately I’m no. 49 on the list at the library…

I too share your pessimism about the conclusions of the book being accepted by those who need to most. Of course the book is making a logical and reasoned argument, while those who most likely accept alternatives, do so, not based on logic and reason, but on faith and emotion. This book is not the most effective way to reach those people I think.

As some of you may have heard, I am being sued for libel by the British Chiropractic Association. I cannot say much at the moment, but I will return to the subject in due course. In the meantime, thanks for the emails of support and the various blogs backing my position. I have not had time to reply – as you can imagine, I am fairly busy at the moment – but the support is much appreciated.

The sad thing is how many reputable schools are now offering degrees in joke disciplines like homeopathy. Well, that and the fact that some state-funded healthcare systems are actually paying for the stuff while making cuts in programs that really work.

Unfortunately a lot of people simply refuse to accept the principle that medical treatments, explanations of phenomea, or public policies should be based on evidence. I sympathise with critics to the extent of noting that “mainstream” medicine sometimes has biases (eg. accounts of ‘hysteria’ and female-specific madness, the racial ‘science’ during the C19th), but it is crazy to reject the whole notion of evidence and the scientific method instead of working to minimise that bias. Regretfully, I think you are right that this won’t sway the fans of quackery, who are more like religious believers than rational consumers.

People are absolutely right to criticize medicine for failing to live up to its own standards. Also, there are major areas of important controversy within conventional medicine: such as how much right to give patients to volunteer for risky procedures or refuse necessary ones, or all the questions about giving anxiety and depression medication to children. That being said, the great thing about properly designed and implemented clinical trials is that the political and professional popularity of a treatment will not influence the results.

Even public perceptions of effectiveness are not important, if it is properly controlled. Because it should be impossible for both subjects and researchers to know who is getting which treatment, any biases about whether an approach is likely to work or not should have an equal effect on the trial group and on the control group. That includes both undue faith people might have in the effectiveness of a treatment as well as any possible undue pessimism.

“We couldn’t be more thrilled to finally get this wonder drug out of the labs and into consumers’ medicine cabinets,” said Tami Erickson, a spokeswoman for AstraZeneca. “Studies show placebo to be effective in the treatment of many ailments and disorders, ranging from lower-back pain to erectile dysfunction to nausea.”

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“Yes, placebo has benefits, but studies link it to a hundred different side effects, from lower-back pain to erectile dysfunction to nausea,” drug researcher Patrick Wheeler said. “Placebo wreaked havoc all over the body, with no rhyme or reason. Basically, whichever side effects were included on the questionnaire, we found in research subjects.”

Given that we all know people who buy into alternative medicine, is it ethical to try to convince them that it is mostly bunk? Alternatively, do we have a moral obligation to try and convince our friends and family members not to waste money on ineffective treatments, or should we ‘tolerate’ their existing beliefs?

The international market for alternative therapies is estimated at US$40 billion. Because so many people use alternative medicine, it provides an excellent vehicle for discussing the nature of scientific research. Yet explaining the evaluation of evidence, balance of probabilities and risk is not easy.

Rose Shapiro’s Suckers and Trick or Treatment by Simon Singh and Edzard Ernst explore the actual worth of alternative medicine and its practitioners, says Olivia Laing

I suspect that neither of these books will find their way to Prince Charles’s bedside table, despite the fact that one is dedicated to him. Both set out to ask why, as a nation, we’re spending £4.5 billion a year on alternative medicine, an umbrella term for therapies that are largely disproven or unproven, occasionally dangerous and often bonkers to boot. The prince is a passionate advocate of alternative medicine and the revelation that the animals of the royal household receive homeopathy is just one of the cherishable details that Rose Shapiro in particular is so adept at relaying.

When I am asked whether I think alternative medicine is quackery, I’m usually careful with my answer and say that it depends on the condition/agent and it is certainly possible that some hypothetical thing out there works. It is impossible to categorically deny that certain alternative therapies may work in specific situations.

Unfortunately, what my response ends up being interpreted as is this: even a medical student thinks that alternative therapies work. Which isn’t what I said, but it is what they hear.

What concerns me most isn’t that people are spending money on something that is of dubious efficacy. People spend money in many different ways that are of dubious utility in my opinion – palm reading, for example – but that’s none of my business. What concerns me is that these ‘natural’ agents may have certain harmful effects, which are poorly controlled in dose and in quality. And because they believe (rightly or wrongly) that the doctor is against the use of these treatments, they don’t tell him/her. This breakdown of communications can result in terrible substance interactions.

People should certainly have a critical mind when it comes to evaluating a doctor’s prescription. There are many good reasons to ask questions, and if it doesn’t add up, they should seek a second opinion or do their own research. Sometimes medicine doesn’t have all the answers (actually, it rarely does). But people should be critical also about the alternative theories. Unless you believe in magic (in which case you wouldn’t need alternative therapies either), you should look critically at the evidence for each specific case.

On the issue of chiropractic therapy, I can’t say that it doesn’t work. Like most things, I’d have to qualify it with the statement ‘it sometimes works.’ But what offends me are the signs that advertise so-and-so being a “Family Chiropractor.” There’s no such thing as a family chiropractor… families don’t need chiropractors. Individuals might, from time to time, but families certainly don’t. (I know that the modern meaning of the word family is very broad, but don’t tell me that non-traditional families is what the advertisement was targeting…) There’s nothing wrong with serving a niche market. Just as a spine surgeon won’t call him/herself a “family spine surgeon,” chiropractors don’t need to (and shouldn’t) pretend that their services would benefit everyone.

I think the moral dilemmas occur because a) very ill people are coaxed into paying for quack treatments they cannot really afford, thus harming their families, b) where people refuse medical treatments that the evidence suggests are effective because they are putting their faith in unproven or disproven ‘treatments’, or c) the treatments themselves may cause harm. These problems occur because unproven or disproven claims ae being made about the efficacy of a treatment, as with false ‘cures’ for HIV/AIDS in South Africa which have led to people dying because they stop taking anti-retroviral drugs eg http://www.guardian.co.uk/world/2008/sep/15/matthiasrath.aids . At minimum, I think governments should pass and enforce legislation ensuring that any so-called treatment is both safe and that claims regarding its efficacy are supported by evidence. Frankly, I don’t understand why someone would not be concerned about the money wasted on ineffective alternative therapies promoted by self-serving liars – at the minimum, the loss is the opportunity cost (i.e. the alternative use for the money) which might well include genuine medical treatment that they could otherwise not afford, and if the quack treatments are covered by health insurers then non-users of quackery will also be paying indirectly for the services.

I wasn’t implying that I didn’t care. But here’s the dilemma: if governments regulate these activities as health practices, they are conferring legitimacy upon them as valid bonafide health care. Which they are not.

If they don’t, then herbal supplements can only be regulated as any other food product. And these rules are much less stringent.

I am happy to tell people what the evidence is when they ask about a specific product that they use (or wish to use). But I don’t know that it is valid for me to say that alternative medicines categorically don’t work (even though many of them don’t).

Governments need not convey any legitimacy for ‘alternative’ healthcare, they only need to pass legislation stating that for anything to be marketed as a treatment (ie. something which cures or helps with a diagnosable medical condition) then it needs to be safe and proved to be effective. In the UK the Advertising Standards Authority evaluates the contents of ads to dissaude (they don’t have legal force) advertisers from lying outright, hence the phrase “healthy-looking hair” in ads because their finding was that hair is dead and thus cannot be healthy. The existence of this oversight doesn’t mean that people believe everything in the adverts or that the ad is ASA approved, it just means that the claims (however trivial or carefully worded) need to be supported by evidence. There are further restrictions in the EU requiring that nutritional supplements must be proved safe. Regulating alternative medicine practitioners seems like a logical extension of these existing laws and practices that stop people from lying about their products and from poisoning people.

It is impossible to categorically deny that certain alternative therapies may work in specific situations.

I suppose that depends on what you mean by ‘work.’ Certainly, putting someone in a plastic box that they believe to be a magical crystal might have a placebo effect. That being said, I think we can categorically deny that it has any inherent medical benefit. I would say the same is true for homeopathy.

This breakdown of communications can result in terrible substance interactions.

This is definitely highlighted in the book. Another phenomenon noted is that people sometimes put real pharmaceuticals in their ‘alternative’ treatments in order to make them effective. Supposedly, this is true of many expensive ‘herbal’ aphrodesiacs. Of course, if you are choosing to take them because Viagra would be dangerous to you for some reason, you can end up in big trouble.

People should certainly have a critical mind when it comes to evaluating a doctor’s prescription.

I agree. In Oxford, I went to see a doctor because of insomnia. When it happened to me at UBC, I would usually take Benadryl because the diphenhydramine is a decent mild sedative. Unfortunately, Benadryl in the UK is a completely different non-drowsy substance (which is incidentally rotten for dealing with allergies). The doctor, who had no medical history and had only spoken with me for a couple of minutes, prescribed Temazepam – a highly addictive benzodiazepine, and the most widely-abused legal prescription drug in the United Kingdom.

I opted not to fill the prescription.

There’s no such thing as a family chiropractor… families don’t need chiropractors.

This is another point made in the book: when patients turn to alternative practitioners as primary care physicians, they can end up in trouble. It is certainly extremely reckless that there are homeopaths and crystal healers out there who will represent themselves of capable of dealing with all medical issues an individual might have.

At minimum, I think governments should pass and enforce legislation ensuring that any so-called treatment is both safe and that claims regarding its efficacy are supported by evidence.

An alternative is to mandate warning labels of the kinds found on cigarette packages.

One suggested in the book is this:

Warning: this product is a placebo. It will work only if you believe in homeopathy and only for certain conditions, such as pain and depression. Even then it is not likely to be as powerful as orthodox drugs. You may get fewer side effects, from this treatment, than from a drug, but you will probably get less benefit.

That saves governments the trouble of driving homeopaths instantly out of business (which might reinforce the sense that they are effective in the minds of some people, while also giving people a fair warning about the efficacy of their approach.

Frankly, I don’t understand why someone would not be concerned about the money wasted on ineffective alternative therapies

I agree, particularly since there is a demonstrably stronger placebo effect for more expensive treatments. That aids con artists (and those deluded few who believe their treatments work and still charge exorbitant rates for them) in bilking sick people (and some insurers) out of large amounts of money.

if governments regulate these activities as health practices, they are conferring legitimacy upon them

I think this depends on how it is done. If you give a government exam to crystal healers, testing how well the understand the aura-altering powers of quartz, you are giving them undue legitimacy. If you require that homeopathic pills be regularly tested for heavy metal contamination, and verify that chiropracters are not damaging the spines of children, you are applying the kind of government safety standards that exist in all sorts of non-medical areas: from licensing roller coaster operators to testing urban air quality.

If they don’t, then herbal supplements can only be regulated as any other food product. And these rules are much less stringent.

Regulating herbal supplements as food products definitely seems problematic, given that we know many herbs have powerful biological effects. While some totally ineffective substances may get touted on the unsuspecting, there are also those who might take something like digitalis or ephedra believing that its ‘natural’ status means it is definitely safe.

I think Sarah is right that some kind of intermediate regime – between the stringency used for prescription drugs and the surprising laxity used for foods – might be the most appropriate way of dealing with herbal treatments.

Written by a best selling science author Singh, who boasts a PhD in particle physics, and Ernst, a professor in complementary therapy, and subtitled ‘alternative medicine on trial’ Singh and Ernst clearly hope to set a standard in the genre. They set out their stall early, first by dedicating the book to the Prince of Wales, whose sympathetic views on alternative medicine are well known, and then by quoting Hippocrates as providing their guiding path.

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The authors say that the key theme running through their book is ‘truth’. And not in any post-modern sense, but instead in the sense of the fundamental question: ‘is alternative medicine effective for treating disease?’. With this in mind, the first chapter of the book is about how science establishes whether medical interventions are effective or not; that is, how the ‘evidence’ is put into ‘evidence-based medicine’.

LIKE many people these days, Lori Potter, a 50-year-old massage therapist living on Kauai, Hawaii, has explored alternative healing for everything from headaches to skin problems. So when she wanted to boost her immune system and lower her stress levels a few years ago, she made an appointment with a visiting practitioner of ayurveda, a medical system that originated in India thousands of years ago and has gained wide popularity in the United States.

He prescribed herbal supplements, which he tested himself for impurities, to help boost her immunity. Soon, Ms. Potter said, she felt more energetic and her digestion was better. After two years, the practitioner stopped visiting the island, and she has not taken any supplements since, she said, because she has not met any practitioners she trusts.

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Michael McGuffin, president of the American Herbal Products Association, a trade group, said that eliminating every trace of arsenic, mercury or lead from products was not a reasonable goal. “If it was, we’d have to find an entirely new food supply,” he said.

Simon Singh is a skeptic in the UK, and a well-known science writer. He coauthored a book called Trick or Treament, Alternative Medicine on Trial basically lambasting many forms of chiropractic as pseudoscience — this is the idea that somehow realigning your spine can fix all sorts of ailments, from toothaches to asthma.

He wrote in article in the UK newspaper The Guardian about this, and the British Chiropractic Association, unsurprisingly, took some exception to it. In fact, they sued him for libel. That lawsuit has been going on for some time, and you can find details by searching Google.

What’s interesting is that Singh could have simply argued that what he said was a free speech comment (or the UK equivalent), which is what’s usually done in these kinds of cases. That lets the paper off the hook, and everyone is happy… though it could be argued there is something of a chilling effect for journalists, who might be afraid to be sued again. But it’s an easy solution that gets the job done.

However, it doesn’t look like that’s what Singh is doing– he and his legal support have turned the tables on the BCA, and are saying that in fact what Singh wrote is true: a lot of chiropractic practices are bogus pseudoscientific quackery. This is beautiful, as it forces the BCA to defend what it does in a court of law. In other words, this goes from a simple libel case to one where an entire sector of garbage “alternative medicine” has to prove what it does is actual medicine.

There is little evidence to show herbal remedies purported to relieve symptoms of menopause actually work, according to a new study.

A growing number of women have turned to black cohosh, evening primrose oil and other natural remedies in recent years to treat hot flashes, irritability and other related problems. Evidence that hormone replacement therapy is associated with a risk of heart disease, stroke and other cardio-vascular problems also may have increased the number of women looking for alternatives to prescription treatments for menopausal symptoms.

“But many Western doctors question the legitimacy of the regimens and their claims of promoting good health, believing detoxification does little to no good, and is possibly harmful.

“It is the opinion of mainstream and state-of-the-art medicine and physiology that these claims are not only ludicrous but tantamount to fraud,” said Dr. Peter Pressman, an internist with the Naval Hospital in Jacksonville, Fla., and a critic of detoxification. “The contents of what ends up being consumed during a ‘detox’ are essentially stimulants, laxatives and diuretics.”’

“There is absolutely no scientific basis for the assertion that the regimens popularly defined as ‘detox’ will augment the body’s own capacity for identifying and eliminating your own metabolic wastes or doing the same for environmental toxins,” Dr. Pressman said. “I advise patients that these detox programs amount to a large quantity of excrement, both literally and figuratively.”

Dr. Frank Lipman, a specialist in integrative medicine in New York and the author of the book “Spent,” puts it a little more delicately: “People are selling a product. There’s a difference between selling a product and practicing good medicine.”

Thousands of parents who claimed that childhood vaccines had caused their children to develop autism are wrong and not entitled to federal compensation, a special court ruled today in three decisions with far-reaching implications for a bitterly fought medical controversy.

The long-awaited decision on three test cases is a severe blow to a grass-roots movement that has argued — predominantly through books, magazines and the Internet — that children’s shots have been responsible for the surge in autism diagnoses in the United States in recent decades. The vast majority of the scientific establishment, backed by federal health agencies, has strenuously argued there is no link between vaccines and autism, and warned that scaring parents away from vaccinating their youngsters places children at risk for a host of serious childhood diseases.

The decision by three independent special masters is especially telling because the special court’s rules did not require plaintiffs to prove their cases with scientific certainty — all the parents needed to show was that a preponderance of the evidence, or “50 percent and a hair,” supported their claims. The vaccine court effectively said today that the thousands of pending claims represented by the three test cases are on extremely shaky ground.

Autism can present in many ways—hence “autism spectrum disorders”—but that range is nothing compared with the diverse techniques that parents use in their attempts to cure, ameliorate, or disrupt the progress of the disease. In the 60-plus years since autism was first described, many methods to treat it have been proposed—one research paper identified 111 recognized treatments or strategies. Studies have found that parents try an average of between 4.3 and seven interventions simultaneously; one family reported using 47 different treatments at one time.

Alas, almost none of these treatments are evidence-based, and some have been clearly demonstrated to be worthless. In dealing with other medical problems, like the common cold, I’ve always annoyed medication-seeking parents by pointing out the obvious: If there is any illness for which 100 treatments are available, you can be sure that none of them works. But with autism, the stakes are much higher.

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The problem is this: When it comes to human behavior, almost any (positive) attention or intervention is likely to be somewhat beneficial. Between 1924 and 1932, some industrial psychologists and efficiency experts studied the Western Electric manufacturing plant in Hawthorne, Ill., to determine what interventions might lead to an increase in productivity. Increase the lighting, even a little bit? Definite improvement for a while. Shorten the workday? Definite improvement for a while. Lengthen it? Definite improvement for a while. Dim the lighting? Definite improvement for a while. It looks as if environmental alteration, especially if coupled with increased attention and perhaps expectation, often leads to change in human behavior. It’s called the “Hawthorne effect.”

The idea that the taste of wine changes with the lunar calendar is gaining credibility among the UK’s major retailers, who believe the day, and even hour, on which wine is drunk alters its taste. Tesco and its rival Marks & Spencer, which sell about a third of all wine drunk in Britain, now invite critics to taste their ranges only at times when the biodynamic calendar suggests they will show at their best.

Marks & Spencer has gone a step further and is advising customers to avoid disappointment from the best bottles by making sure not to open them on “root” days…

In other quarters, doubts remain. Waitrose’s wine department has investigated the idea and cannot see a correlation. Many scientists have little time for biodynamic wine, pointing out that the movement’s guru, Rudolf Steiner, claimed to have conceived the concept after consulting telepathically with spirits beyond the realm of the material world. Among his other works are claims that the human race is as old as the Earth and descended from creatures with jelly-like bodies, and a belief that men’s passions seep into the Earth’s interior, where they trigger earthquakes and volcanoes.

Sex-change surgery also delisted to put a combined $42 million toward seniors’ home care, Liepert says

BY JODIE SINNEMA, THE EDMONTON JOURNAL

Albertans will no longer be able to claim chiropractic care starting this summer, after the government delisted chiropractor services from its provincial health plan.

The cut, which will save approximately $53 million, will mean patients will be out up to $200 each year.

The province also cut coverage for gender reassignment surgery or sex-change operations, a move that will save $700,000, leaving about 20 patients each year on the hook for procedures that cost anywhere between $18,000 and $70,000.

The preliminary hearing for the libel case brought against Simon Singh by the British Chiropractic Association will be heard at the English High Court on Thursday. It may last up to two days.

As this is a preliminary hearing there will not be any examination or cross-examination of evidence. There will be no experts.

Instead the preliminary hearing will, as its name suggests, deal with certain preliminary issues:

– can the BCA actually show that they have been defamed?
– were the passages complained of in the original article “comment” or a statement of “fact”? Or both?
– what did the passages mean?

On the first point, if the court does not accept the BCA has an appropriate “reputation” or, even if it has, its reputation has not been defamed, then the case can be struck out straight away. If so, the BCA here will not have even got to first base.

It is unlikely that the court will make its judgment this week, but it should be due well within a month. The main hearing, if it still goes ahead, will likely be after September 2009.

Please do come along if you are in London. There is plenty of room in court. I will be in the main hall of the Royal Courts of Justice at the Strand from 9.30am on Thursday, by the information desk. Those who come along can come with Simon at lunch, and perhaps after the hearing, for a chat at the Knights Templar pub on Chancery Lane.

There will updates on the Jack of Kent blog on Thursday and Friday, and Jack of Kent will also be twittering from well outside the court, on the Strand, at then end of each day’s hearing:

Simon Singh, author of Fermat’s Last Theorem and The Code Book, was sued for libel by The British Chiropractic Association for comments he wrote in a column in The Guardian:

The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

As part of libel litigation, the court does have to rule as to the meaning of the relevant passages.

“The ruling was by Sir David Eady, the presiding judge. He has decided the “meaning” which should be given to the passage complained of in Simon Singh’s original article.

A sham form of acupuncture using toothpicks that don’t penetrate the skin works as well as traditional needle acupuncture for relieving back pain, researchers report in the May 11 Archives of Internal Medicine. Both procedures outperformed non-acupuncture alternatives, such as medication alone.

When the Lights Go Out
What can reality TV teach us about clinical drug trials?
By Darshak Sanghavi
Posted Wednesday, May 13, 2009, at 11:33 AM ET

Epidemiologists call this the problem of “surrogate endpoints,” and it’s no surprise to fans of reality television. Garnering the greatest number of text-messaging votes after a brief performance doesn’t always mean you’ll be a successful pop star; winning the final rose after an on-air courtship doesn’t mean you’ll have a happy marriage; and getting higher scores on a simple rating scale of attention-deficit symptoms doesn’t mean you’ll later succeed in school. In medicine, this problem happens all the time.

Few drug-trial studies have the time or money to study the actual health outcomes that people care about, such as whether the middle-aged man avoids a heart attack after a few decades, the hyperactive first-grader holds down a good job someday, or the menopausal woman remains free from a hip fracture when she’s elderly. Waiting for these events would stifle any meaningful innovation, so doctors pick surrogate endpoints, which they hope serve as short-term checkpoints. Thus drugs trials for the preceding examples may just decide to measure the middle-aged man’s cholesterol level, the youngster’s symptom checklist for hyperactivity, and the woman’s bone density with a DEXA scan.

When chiropractors drag a top science writer into the libel courts, the country has lost its backbone

Nick Cohen
The Observer, Sunday 31 May 2009

This week, Simon Singh, one of Britain’s best science writers, will decide whether to carry on playing a devilish version of Who Wants to be a Millionaire? He has already lost £100,000 defending his right to speak frankly. He could walk away. No one would think the worse of him if he did. Or he could go on and risk losing the full million by ensnaring himself in the rapacious world of an English judiciary that seems ever eager to bow to the demands of Saudi oil billionaires, Russian oligarchs and the friends of Saddam Hussein to censor critics and punish them with staggering damages and legal fees.

It seems no choice at all. Any friend Singh phoned would tell him to cut his losses and run. But if he were to turn to the audience, he would hear scientists all but screaming at him to go to the Court of Appeal and challenge a judgment that threatens the robust discussions open societies depend on. A national defence campaign is ready to roll on his command. At a preliminary support meeting, a cheering crowd acclaimed him as a free-speech champion.

In January, Oprah Winfrey invited Suzanne Somers on her show to share her unusual secrets to staying young. Each morning, the 62-year-old actress and self-help author rubs a potent estrogen cream into the skin on her arm. She smears progesterone on her other arm two weeks a month. And once a day, she uses a syringe to inject estrogen directly into her vagina. The idea is to use these unregulated “bio-identical” hormones to restore her levels back to what they were when she was in her 30s, thus fooling her body into thinking she’s a younger woman. According to Somers, the hormones, which are synthesized from plants instead of the usual mare’s urine (disgusting but true), are all natural and, unlike conventional hormones, virtually risk-free (not even close to true, but we’ll get to that in a minute).

Next come the pills. She swallows 60 vitamins and other preparations every day. “I take about 40 supplements in the morning,” she told Oprah, “and then, before I go to bed, I try to remember … to start taking the last 20.” She didn’t go into it on the show, but in her books she says that she also starts each day by giving herself injections of human growth hormone, vitamin B12 and vitamin B complex. In addition, she wears “nanotechnology patches” to help her sleep, lose weight and promote “overall detoxification.” If she drinks wine, she goes to her doctor to rejuvenate her liver with an intravenous drip of vitamin C. If she’s exposed to cigarette smoke, she has her blood chemically cleaned with chelation therapy. In the time that’s left over, she eats right and exercises, and relieves stress by standing on her head. Somers makes astounding claims about the ability of hormones to treat almost anything that ails the female body. She believes they block disease and will double her life span. “I know I look like some kind of freak and fanatic,” she said. “But I want to be there until I’m 110, and I’m going to do what I have to do to get there.”

That was apparently good enough for Oprah. “Many people write Suzanne off as a quackadoo,” she said. “But she just might be a pioneer.” Oprah acknowledged that Somers’s claims “have been met with relentless criticism” from doctors. Several times during the show she gave physicians an opportunity to dispute what Somers was saying. But it wasn’t quite a fair fight. The doctors who raised these concerns were seated down in the audience and had to wait to be called on. Somers sat onstage next to Oprah, who defended her from attack. “Suzanne swears by bioidenticals and refuses to keep quiet. She’ll take on anyone, including any doctor who questions her.”

That would be a lot of doctors. Outside Oprah’s world, there isn’t a raging debate about replacing hormones. Somers “is simply repackaging the old, discredited idea that menopause is some kind of hormone-deficiency disease, and that restoring them will bring back youth,” says Dr. Nanette Santoro, director of reproductive endocrinology at Albert Einstein College of Medicine and head of the Reproductive Medicine Clinic at Montefiore Medical Center. They just don’t need as much once they get past their childbearing years. Unless a woman has significant discomfort from hot flashes—and most women don’t—there is little reason to prescribe them. Most women never use them. Hormone therapy can increase a woman’s risk of heart attacks, strokes, blood clots and cancer. And despite Somers’s claim that her specially made, non-FDA-approved bioidenticals are “natural” and safer, they are actually synthetic, just like conventional hormones and FDA-approved bioidenticals from pharmacies—and there are no conclusive clinical studies showing they are less risky. That’s why endocrinologists advise that women take the smallest dose that alleviates symptoms, and use them only as long as they’re needed.

Singh is a serious and amiable man, whose accounts of the solving of Fermat’s last theorem and code breaking won high praise and provoked no controversy. Last year, he published Trick or Treatment? with Professor Edzard Ernst on the reliability of “alternative medicine”, and devoted a chapter to the strange history of chiropractic treatments. One Daniel David Palmer invented the therapy in Davenport, Iowa, in 1895, when he convinced himself that he had cured a janitor’s deafness by “racking” his back.

His son, Bartlett, described how he beat them with “straps until we carried welts, for which Father was often arrested and spent nights in jail”. Bartlett bought the first car Davenport had seen and paid his father back by running him down on the day of the Palmer School of Chiropractic Homecoming Parade.

Palmer died of his injuries a few weeks later, but his ideas lived on. In 2008, the British Chiropractic Association (BCA) announced that its members could help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying. Writing in the Guardian, Singh said the claim was “bogus”. Chiropractic treatments may help relieve back pain, but Professor Ernst had examined 70 trials and found no evidence that they could relieve other conditions.

I am glad to say that on Monday I [Simon Singh] will apply to the Court of Appeal in an attempt to overturn the recent negative ruling on meaning in my libel case with the British Chiropractic Association.

Also, Sense About Science have launched a campaign linked to my libel case and focussing on the need to overhaul the English libel system, which is deeply flawed and which therefore has a chilling effect on journalism.

The campaign has issued a statement of support, which has already been signed by an incredible list of people, including James Randi, Richard Dawkins, Ricky Gervais, Sir Martin Rees, Penn & Teller, Stephen Fry, Martin Amis and Steve Jones. It would be terrific if you would also sign up to the statement and (better still) encourage others to sign up. It is conceivable that this campaign could help reform the English libel laws (which unfortunately affect overseas journalists too). Please help us move closer to having a free press.

“David H. Newman, M.D. has an interesting article in the NY Times where he discusses common medical treatments that aren’t supported by the best available evidence. For example, doctors have administered ‘beta-blockers’ for decades to heart attack victims, although studies show that the early administration of beta-blockers does not save lives; patients with ear infections are more likely to be harmed by antibiotics than helped — the infections typically recede within days regardless of treatment and the same is true for bronchitis, sinusitis, and sore throats; no cough remedies have ever been proven better than a placebo. Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment, and knee surgery is no better than sham knee surgery where surgeons ‘pretend’ to do surgery while the patient is under light anesthesia. Newman says that treatment based on ideology is alluring, ‘but the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.’ The Obama administration’s plan for reform includes identifying health care measures that work and those that don’t, and there are signs of hope for evidence-based medicine: earlier this year hospital administrators were informed by the Centers for Medicare and Medicaid Services that beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009. ‘After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country,’ writes Newman, ‘the agency has demonstrated that minds can be changed.'”

It looks like an admission of guilt to me. The McTimoney Association, a British chiropractic group, has sent out mail to its members urging them to immediately shut down all of their websites. Why? Because, as a result of the Simon Singh fracas, people are becoming aware that chiropractors are making “claims for treatment that cannot be substantiated with … research”, so they’re trying to make the quackery go away fast. (By the way, my ellipsis removed the word “chiropractic”; I would not trust chiropractic research, but they can’t even provide that). It’s a hilarious message — they flat out admit that common claims made on chiropractic websites put them at risk for prosecution.

The American Medical Association voted Tuesday to recommend that hospitals ban doctors’ iconic white lab coats, citing evidence that the garment contributes to the spread of infection. Indeed, a number of studies have shown that the coats harbor potentially harmful bacteria (and may cause “white coat hypertension”). If white coats are so bad, why do doctors still wear them?

After spending $2.5 billion, the National Center for Complementary and Alternative Medicine has found that most alternative medicine cures—like echinacea, ginkgo biloba, and shark cartilage—do not work. What do you think?

For everyone following my libel case, the bad news is that my application to appeal seems to have been rejected. I say “seems” because I have not yet seen the official ruling as the letter is still in the post. However, there seems to have been a leak and my options are already being discussed by various bloggers. As usual, Jack of Kent has provided a clear summary of the situation:

The Court of Appeal’s refusal is obviously disappointing, but I remain in good spirits. I will not be making a decision about my response until I have seen the official letter and the details of the refusal, and I will also need to time to discuss the situation with friends, colleagues, supporters and family. In the meantime, while my particular libel case is ongoing, it continues to raise a whole series of arguably more important issues, particularly the appalling state of English libel laws. I am pleased that the Culture Secretary has agreed to meet with signatories of the Keep Libel Laws out of Science campaign statement to hear how the laws affect science writers. We are also pursuing a meeting at the Ministry of Justice and with front benchers in other departments to lobby for a change in the law.

“At each stage of the legal process I have very carefully weighed up the options and discussed the situation with legal experts, friends and supporters. For example, right now, it seems obvious that I should persist with the appeal process – I accept that that an oral application to appeal stands less than a 50% chance of success, but the additional costs are relatively small and the potential rewards are enormous; in the long run, if I can successfully win my case, I could recoup my own costs, force the British Chiropractic Association to pay its own costs and reinforce my concerns about the lack of evidence surrounding some chiropractic treatments.

…

There are a few possibilities if the oral application to appeal is rejected.

The first option, having exhausted the English appeal process on the issue of meaning, would be to take the case to the European Court of Human Rights (ECtHR), probably with reference to Article 10, which is the right to free expression.

Alternatively, I could return to the preliminary hearing, which is currently unfinished. The outstanding aspect of my defence (not covered in the May preliminary hearing) questions whether a corporation without shareholders can sue for libel. The BCA’s reputation is with its members and not the public, because it serves its members and does not trade with the public; my article was aimed at the public and would not have damaged the BCA’s reputation with its members.”

People with conditions such as HIV, TB and malaria should not rely on homeopathic treatments, the World Health Organization has warned.

It was responding to calls from young researchers who fear the promotion of homeopathy in the developing world could put people’s lives at risk.

The group Voice of Young Science Network has written to health ministers to set out the WHO view.

However practitioners said there were areas where homeopathy could help.

In a letter to the WHO in June, the medics from the UK and Africa said: “We are calling on the WHO to condemn the promotion of homeopathy for treating TB, infant diarrhoea, influenza, malaria and HIV.

“Homeopathy does not protect people from, or treat, these diseases.

“Those of us working with the most rural and impoverished people of the world already struggle to deliver the medical help that is needed.

“When homeopathy stands in place of effective treatment, lives are lost.”

Dr Robert Hagan is a researcher in biomolecular science at the University of St Andrews and a member of Voice of Young Science Network, which is part of the charity Sense About Science campaigning for “evidence-based” care.

Saint of Skepticism James Randi is profiled in the current issue of the SF Weekly. The reporter attended Randi’s annual Las Vegas conference, the Amazing Meeting, which sounds like a cult revival for unwavering disbelievers and anti-Forteans. From the SF Weekly:

Randi has debunked more than 100 psychics and faith healers in a quest to rid the world of hucksters. It also makes him the subject of scorn among purveyors of the paranormal, true believers who say Randi has made himself rich, pulling in nearly $200,000 a year from his foundation, at the expense of others’ careers. His foundation has been hemorrhaging money, and Randi, who has spent his career challenging the notion of an afterlife, now faces his own mortality. He has intestinal cancer and may not have long to live. He has been a commanding presence for four decades, but it’s unclear who could fill his role as the face of the skeptic community…

The James Randi Foundation put together its first skeptics’ conference in 2003. That first year in Fort Lauderdale, the event drew just 150 attendees. In the years since, it has grown to become the largest gathering of critical thinkers, doubters, heretics, and nonbelievers in the world. More than 1,100 conferees paid about $300 each for admission this year. They come to hear some of the most famous voices in critical thinking — Adam Savage, San Francisco–based cohost of the Discovery Channel’s MythBusters; Bill Prady, cocreator of CBS’ The Big Bang Theory — and to discuss Randi’s favorite topic, skeptical inquiry, a discipline devoted to debunking psychics, faith healers, con artists, and ghost whisperers through the holy miracle of old-fashioned science.

‘In Britain, libel laws are censoring the ability of journalists to write stories about bogus science. Simon Singh, a Ph.D. physicist and author of several best-selling popular-science books, is currently being sued by the British Chiropractic Association (BCA) for saying that there is no evidence for claims that visiting a chiropractor has health benefits. A year earlier, writer Ben Goldacre faced a libel suit for an article critical of Matthias Rath, who claimed that vitamin supplements can treat HIV and AIDS in place of conventional drugs like anti-retrovirals. In Britain, libel laws don’t have any presumption of innocence– any statement made is assumed to be false unless you prove it’s true. Journalist are running scared.’

A US couple who prayed rather than seeking medical attention for their dying daughter have been sentenced to six months in jail.

Dale and Leilani Neumann, of Wisconsin, could have received up to 25 years in prison over the 2008 death of Madeline Neumann, who was known as Kara.

The 11-year-old died of an undiagnosed but treatable form of diabetes.

Judge Vincent Howard ordered the couple to serve one month in jail each year for the next six years.

One parent will serve the term in March and the other in September.

The judge told the Neumanns this would give them time to “think about Kara and what God wants you to learn from this”.

He added that they were “very good people, raising their family, who made a bad decision, a reckless decision”.

He added: “God probably works through other people, some of them doctors.”

In addition to the custodial sentence, the Neumanns were also put on 10 years’ probation, as part of which they must allow a nurse to examine their two youngest surviving children at least once every three months, and must immediately take their children to a doctor in case of any serious injuries.

Recently, science writer Simon Singh was sued by the British Chiropractic Association for having the audacity of telling the truth in a newspaper article about chiropractic: while it may have some small efficacy when treating back problems, there is exactly zero good evidence that it can treat illnesses, and in fact can be very dangerous when people get their neck manipulated.

The Australian Skeptics posted Simon’s original article so that it would get more attention. And it worked, kinda: like a fly to honey, one chiropractor took offense at what was written, and decided to send them a nearly logic-free letter. That’s fine, and pretty much what I expect from a vocal alt-med devotée. As justified, Eran Segev, president of the Australian Skeptics, responded.

In an incredible press release published either yesterday or earlier today, the British Chiropractic Association made the serious and completely groundless accusation that Simon Singh had been motivated by malice in writing his original article.

This press release has now been hastily and silently switched for a modified one which does not make this significant allegation of improper conduct. However, the hardrives of dozens of Twitterers will evidence that this allegation was indeed published.

I spent Tuesday night at the Barley Mow pub in Westminster, central London, surrounded by 150 people who were outraged at the state of English libel laws. The event, which is part of a series of Skeptics in the Pub events around the country, started with a misquote from Star Wars that set the tone of optimism for the entire evening: “We are more possible than you can powerfully imagine.”

The mob, clamouring for a more liberal approach to free speech, was made up largely of bloggers, academics and sceptics. They all passionately share the same belief, which is that the freedom to criticise fairly and strongly is the cornerstone of debate and progress.

One of the main fears, expressed repeatedly during the evening, was the sheer cost of a libel case. Although the damages at stake might be just £10,000, going to trial can mean risking more than £1m. This means that a blogger has to ask whether he or she can afford the possibility of bankruptcy. Even if a blogger is 90% confident of victory, there is still a 10% chance of failure, which is why bloggers often back down, withdraw and apologise for material they believe is true, fair and important to the public.

Why has Mr Justice Eady been allowed to conduct a one-man campaign against free speech?

By George Monbiot. Published in the Guardian 20th October 2009

Trafigura’s super-injunction is weird for lots of reasons. But the strangest fact is this: it has nothing to do with the Honourable Mr Justice Eady. The company’s lawyers injuncted the Guardian, injuncted their injunction and tried to injunct reports of Parliament’s proceedings. And they did all this without enlisting the help of the hanging judge of the Queen’s Bench Division, the legal censor who appears to be fighting a one-man battle against freedom of speech. That’s quite an achievement.

But even as the Trafigura case was being discussed in parliament, the court of appeal was handing down yet another damning ruling on Sir David Eady’s judgements. In May this year, Eady presided over the case brought by the British Chiropractic Association against the science writer Simon Singh. Writing in the Guardian, Singh maintained that the BCA, which claimed that its members “can help treat children with colic, sleeping and feeding problems … happily promotes bogus treatments”. The association sued him for libel. Despite the prospect of massive costs, Singh bravely chose to defend himself.

To the astonishment of lawyers, journalists and scientists, Eady, who is England’s senior libel judge, decided that Singh was accusing the BCA of being consciously dishonest. This meant that he didn’t have a legal leg to stand on, as the libel laws, uniquely, place the burden of proof on the defendant. To win the case, Singh would have to prove that the BCA knew the treatments were bogus and was acting fraudulently. He didn’t believe this and it hadn’t been his intention to suggest it. But now he had to prove to the jury that he could see inside the BCA’s collective mind and discern that it was knowingly promoting false information.

Though this meant that his costs – which had already reached £100,000 – would climb even higher, Singh appealed. Last week the appeal court struck Eady’s ruling down, deciding that his interpretation was “legally erroneous.” (Sadly this doesn’t conclude the case). Its judgement hasn’t yet been transcribed, but people who were in court claim that it damns Eady as fiercely as any previous ruling. That’s saying quite a lot.

SerpensV passes along the news that German scientists have found direct evidence that the spinal cord is involved in the placebo effect (whose diminishing over time we discussed a bit earlier). “The researchers who made the discovery scanned the spinal cords of volunteers while applying painful heat to one arm. Then they rubbed a cream onto the arm and told the volunteers that it contained a painkiller, but in fact it had no active ingredient. Even so, the cream made spinal-cord neural activity linked to pain vanish. ‘This type of mechanism has been envisioned for over 40 years for placebo analgesia,’ says Donald Price, a neuroscientist at the University of Florida in Gainesville, who was not involved in the new study. ‘This study provides the most direct test of this mechanism to date.'”

Your thoughtful and nuanced exposition does not neglect these underlying factors. But I wonder whether their existence might point to something more radical. Perhaps the cure for denialism is not a greater infusion of scientific thinking or rationality but rather a solution to the underlying issues that drive people toward homeopathic placebos or worse. Would people flee so readily into the arms of Andrew Weil if they had more time with caring doctors whose services they could actually afford and if they didn’t hear so many horror stories about medical errors committed at hospitals?”

TORONTO — A new study shows an increasingly popular treatment used by elite athletes to speed healing doesn’t work better than a placebo when it comes to tendon injuries.

The injected treatment, called platelet-rich plasma or PRP, has been used by a range of athletes, including Olympic figure skating hopeful Patrick Chan.
But the scientific evidence supporting its usefulness has been preliminary.

Now the first known randomized controlled trial of the treatment found it didn’t speed recovery in people who suffered from injuries of the Achilles tendon.

Acupuncture may be an effective way of easing severe period pain, a South Korean review of 27 studies suggests.

Researchers said there was “promising evidence” for acupuncture in treating cramps, but that more work was needed.

In the British Journal of Obstetrics and Gynaecology, they noted two studies found little difference between real and sham acupuncture in treating pain.

Acupuncture is a less contentious form of complementary medicine than some, but its value is still disputed.

Period pain can be severe in some women and may be accompanied by nausea, diarrhoea, migraine and backache. Common treatments include pain killers, applying heat and exercise – although a recent study questioned the efficacy of the latter.

This latest review involved 27 studies – which included nearly 3,000 women. They addressed a variety of forms of acupuncture – from classical to acupoint injection.

My ongoing libel case goes to the Court of Appeal on Tuesday, when the meaning of my article will be decided by three of the most senior judges in the country. Whatever the outcome, the ruling could have a major impact on how English libel laws affect free speech in Britain and around the world.

I have written about the case at length in previous emails, so I will not summarise the story again. In fact, this will be the last time that I mention the libel case until the whole legal process has been completed. So, if you want to keep up to date with the case then please track events on twitter by following @slsingh or #libelreform

My final words on the subject are simply a plea to sign up to the petition for libel reform. English libel laws have a damaging impact on writers around the world, so we welcome signatories from all countries. My own writing has effectively been halted for almost two years because of the extortionate costs of libel and the painfully slow legal process. More generally, the libel laws can effecively crush criticism by bloggers, scientists, journalists, humans rights organizations and many others. Please sign up at http://www.libelreform.org/sign

And, if you have already signed the petition, then please encourage others to sign up. If you want to remind yourself of the reasons that might persuade your friends, family and colleagues to sign up to libel reform then please visit the link at the end of the previous paragraph.

Each bubble represents a specific use—or group of uses—for a dietary supplement. The bigger the bubble, the more popular the supplement is, as measured in Google hits. The higher on the chart, the more solid the evidence supporting that particular supplement for that particular use.”

“Even when “significance” is properly defined and P values are carefully calculated, statistical inference is plagued by many other problems. Chief among them is the “multiplicity” issue — the testing of many hypotheses simultaneously. When several drugs are tested at once, or a single drug is tested on several groups, chances of getting a statistically significant but false result rise rapidly. Experiments on altered gene activity in diseases may test 20,000 genes at once, for instance. Using a P value of .05, such studies could find 1,000 genes that appear to differ even if none are actually involved in the disease. Setting a higher threshold of statistical significance will eliminate some of those flukes, but only at the cost of eliminating truly changed genes from the list. In metabolic diseases such as diabetes, for example, many genes truly differ in activity, but the changes are so small that statistical tests will dismiss most as mere fluctuations. Of hundreds of genes that misbehave, standard stats might identify only one or two. Altering the threshold to nab 80 percent of the true culprits might produce a list of 13,000 genes — of which over 12,000 are actually innocent.”

This XKCD comic is a concise and convincing refutation of claims about crystal healing, psychic healing, and the like:

Of course, there are all sorts of reasons why people falsely believe that ineffective treatments work. These include placebo effects and regression to the mean. Unfortunately, many of the people who believe that crystals have magical properties also believe that medical treatments that are actually effective either do not work, or have terrible side-effects.

In a 1997 book, Hystories: Hysterical Epidemics and Modern Media, which I’d brought along to pass time on the mountain, Elaine Showalter, a literary critic and medical historian, describes how indeterminate feelings of malaise can become named, reified, and packaged into quasi-official illnesses.

“Initially,” she wrote, “patients are people with a bewildering set of troubling symptoms and a wide range of explanations for them.” Once persuaded that they have, say, chronic fatigue syndrome or anorexia nervosa, their malady finds an anchor in the medical world. “They may become addicted to their symptoms, and embark on the career of being a particular kind of patient,” she wrote, “with a self-supporting network of friends, activities, doctors, and treatments.” Showalter doesn’t dispute that for the sufferers the symptoms are real and debilitating. But that doesn’t mean that they are not also psychological.”

“In fact, beyond the sheer number of casualties, there’s not even reason to single out radium as unique for being abused as a medicine. Byers and the illnesses suffered by the Radium Girls cooled the public’s enthusiasm for radium goods, but other elements stepped into the spotlight. Pretty much every natural element on the periodic table has been touted at some point as a miracle cure for something, and you can find pills or supplements of many online even today. Year to year the in-vogue elements change, but the claims—Cure terminal diseases! Rid your body of toxins!—stay the same. If studying the periodic table taught me nothing else, it’s that the credulity of human beings for periodic table panaceas is pretty much boundless.”

Even taken as instructed, experts say it can cause severe vomiting and diarrhoea – and mixing it wrongly could lead to respiratory failure.

The Food Standards Agency is seeking to track down any UK-based sellers.

The supplement, which claims to have beneficial effects against a wide range of illnesses, ranging from HIV and hepatitis to H1N1 flu, has already been the subject of warnings from the Food and Drug Agency (FDA) in the US.

Now UK consumers are being urged to dispose of the supplement as soon as possible, and help the Food Standards Agency and local authorities find suppliers in this country.

CONTRARY to widespread belief in China and South-East Asia, the rhinoceros horn has no proven medicinal or aphrodisiac qualities. Its effect, some scientists say, is the same as chewing your fingernails. It is made of the same stuff, agglutinated hair. Yet rhino horn is currently worth more than gold, selling for up to $60,000 a kilo. That is why a beast that has been on earth for some 60m years is fighting for its existence.

So far this year, at least 260 South African rhinos have been illegally killed, a rate of nearly one a day and well over double last year’s total. Almost all were shot for their horns; these days, few are taken for bush meat. South Africa is home to more than 90% of the world’s white rhinos (the adjective is a corruption of the Dutch word wijde, meaning wide, a reference to the species’s broad mouth) and around a third of the rarer black one.

Until 1970 all had been reasonably well. Then oil prices soared, resulting in a seven-fold increase in income per head in Yemen, where elaborately carved rhino-horn dagger handles are prized as a sign of status and wealth. Yemenis rapidly became the world’s biggest importers of rhino horn. By 1980 half the world’s rhinos, by some estimates, had disappeared.

Doctors are routinely missing or ignoring moments that beg for empathy and need more training in responding to human emotions, an article in Canada’s leading medical journal says.

Researchers from the University of Toronto and Duke University in Durham, North Carolina say studies suggests doctors fail up to 90 per cent of the time to respond to emotional cues from their patients.

“Empathy is the ability to understand another’s experience, to communicate and confirm that understanding with the other person and to then act in a helpful manner,” the authors write in the Canadian Medical Association Journal.

The team points to a recent study, published in the Archives of Internal Medicine, where researchers analyzed 20 transcripts from recordings of 137 consultations between doctors at a U.S. Veterans Affairs hospital and patients with lung cancer. In all, 384 moments or “empathetic opportunities” when patients expressed fears, worries or concerns were identified.

Poor expectations of treatment can override all the effect of a potent pain-relieving drug, a brain imaging study at Oxford University has shown.

In contrast, positive expectations of treatment doubled the natural physiological or biochemical effect of the opioid drug among the healthy volunteers in the study.

The study of the placebo effect – and its opposite the nocebo effect – is published in Science Translational Medicine. The findings suggest that doctors may need to consider dealing with patients’ beliefs about the effectiveness of any treatment, as well as determining which drug might be the best for that patient.

‘Doctors shouldn’t underestimate the significant influence that patients’ negative expectations can have on outcome,’ says Professor Irene Tracey of the Centre for Functional Magnetic Resonance Imaging of the Brain at Oxford University, who led the research.

A public-health scandal has now awoken the French to the dangers of a heavy drug-consumption culture. This week Jacques Servier, founder and boss of Servier Laboratories, was due to appear in court in connection with a criminal lawsuit brought by patients who took a drug called Mediator. It was originally licensed for diabetics, but family doctors began to prescribe it in the mid-1990s as an appetite-suppressant. Despite the ringing of alarm bells over the years about its links to heart disease, both in other countries and within the French medical profession, the drug was not withdrawn in France until 2009. By that time, according to different estimates, between 500 and 2,000 people who had been taking the drug had died.

The story has rattled the French, knocking their faith in the competence of the public-health authorities. A report into the Mediator affair ordered by Xavier Bertrand, the health minister, published last month, is devastating. It observes “grave failings” on all sides, from the laboratory’s “relentless” campaign to continue to market the drug “out of line with its medical properties”, to the health authorities’ cumbersome bureaucracy. “The medical-drug chain functions today in such a way that the doubt benefits not the patients or public health, but the companies,” it concludes.

But if plants are, for the most part, as medicinally useless as he believes, how does he explain their centrality to the beliefs and practices of medical practitioners for centuries?

“Because they believed in the tooth fairy,” he says matter of factly. “They had no concept of illness or of chemistry or biochemistry. They believed all plants had been put on the earth by the creator for mankind’s use. So if the plant had a particular shape, it indicated that the creator had put it on the planet for a particular use.”

Citing as an example the use of blue liverwort, Hepatica nobilis , once cultivated as a liver tonic because its three-lobed leaf form mirrored the shape of the liver, he says, “It was absolute rubbish. They had no idea how the body worked.” In the 1880s, at the height of its popularity, those taking it to cure feelings of “liverishness” were stuck down by jaundice because the plant was in fact toxic to the liver.

MedicineThere is no alternative
Virtually all alternative medicine is bunk; but the placebo effect is rather interesting

IT IS, you might suppose, always good to have an alternative. In medicine, though, that is a controversial proposition. Alternative and complementary medicine are mostly quackery. Yet they are very popular. Clearly, they have something that mainstream medicine does not. The question is, what?

A few treatments (mostly herbs containing active drug molecules) do have proven benefits. A few others look worthy of further investigation. But from acupuncture, via homeopathy, to “quantum healing”, the vast majority, some 95%, offer nothing more than the placebo effect—the strange and inadequately explained tendency of certain medical conditions to respond to anything the patient thinks is directed at treating them, even when the treatment in question could not possibly have a direct effect on the disease.

It is thus a great pity that Edzard Ernst, the first professor of alternative medicine (that is, real scientific professor) and the man who demonstrated that 95% of the industry was hokum, is about to retire early (see article). It is an even greater pity that funding to his department at Britain’s Exeter University looks likely to be cut. For the message needs to be broadcast that alternative medicine is a colossal waste of money. Globally, the industry is estimated to be worth some $60 billion a year. That is a lot to pay for placebos.

The basic idea of classical chiropractic is that “subluxations” are the cause of most medical problems. According to classical chiropractic, a “subluxation” is a misalignment of the spine that allegedly interferes with nerve signals from the brain. However, there is no scientific evidence for spinal subluxations and none have ever been observed by medical practitioners such as orthopedic surgeons, neurosurgeons, or radiologists. On May 25, 2010, The General Chiropractic Council (GCC), a UK-wide statutory body with regulatory powers, issued the following statement:

The guidance document was published on Tuesday. It is based on a review of the available scientific evidence on the efficacy of over-the-counter cold remedies, supplements such as echinacea, zinc and vitamin C, humidifiers, antihistamines and even honey.

If you are a parent looking for a way to make it all better, the conclusions are rather bleak. Virtually nothing really works, the paper suggests.

There’s no real proof over-the-counter cold and cough products work in children, but there’s a fair amount of evidence that use of these medications in kids can lead to problems. A U.S. injury surveillance system found that, in 2004-2005, six per cent of emergency department visits by children under 12 that were related to medication use involving over-the-counter cold remedies.

Medicine and its rivalsThe believers
Alternative therapies are increasingly mainstream. That means headaches for scientists—and no cure in sight

THREE DOZEN doctors-in-training recently sat in a conference room in Tucson. Arizona sunshine streamed through open French windows. On the floor were votive candles and peacock feathers, symbols of healing. It was the closing ceremony in a month-long course at the Centre for Integrative Medicine at the University of Arizona, promoting the notion that doctors should use alternative treatments alongside conventional ones. Speaking to the students was Andrew Weil, a doctor and campaigner who heads the centre.

Dr Weil is a diminutive Santa Claus with a not-so-diminutive brand. He writes books and sells products (such as the Dr Andrew Weil for Origins™ Mega-Mushroom Skin Relief Soothing Face Lotion, for $61). Profits go to his foundation. On this occasion he was in his role as teacher, explaining the importance of nutrition in keeping patients well. That is a doctor’s task, he said, not merely treating the sick.

Few in mainstream medicine would disagree with such an approach. But Dr Weil continued by saying that evidence-based medicine, at its worst, “is exactly analogous to religious fundamentalism.” He urged the students to promote integrative medicine. Together, they would be the future of American health care.

They are well on their way. By one recent count four in ten American adults use some form of alternative therapy. If Dr Weil’s flourishing business and other programmes are any indication, these will grow even further. For six decades double-blind, randomised, placebo-controlled trials have helped doctors to sort science from opinion and to sift evidence from anecdote. Now those lines are blurring.

The evidence for alternative treatments varies wildly. Some herbal remedies broadly meet the test of mainstream medicine. St John’s wort has antidepressive effects (though quite how it works is not completely clear). Chinese herbs may improve chemotherapy for colon cancer. Acupuncture can relieve nausea and some types of pain—though for other ailments it seems no more effective than a placebo, according to Edzard Ernst, who led the study of alternative medicine at Exeter University. Homeopathy is more controversial. Believers say substances which in large quantities may cause symptoms of illness can cure them in highly diluted form, thanks to an imprint left on the water. Sceptics deride both that claim and the principle behind it.

SIR – One reason why patients have faith in unproven alternative medicine is that conventional treatments of terminal diseases tend to have low success rates and can lead to a poor post-treatment quality of life. Doctors prescribe futile care either because of fear of litigation or the wishes of the patient. When people experience the pain of futile treatments, such as the side effects from chemotherapy, it is small wonder that they seek out alternatives.

Brendan Dean Zhi Min
Singapore

SIR – The most telling comment on homeopathy I have read was by Abraham Lincoln when ridiculing the views of Stephen Douglas in one of their famous debates: “As thin as the homeopathic soup that was made by boiling the shadow of a pigeon that had starved to death.”

TO SUGGEST curbing an American’s health care is like threatening to kidnap his child. More care, he believes, must be better care. On Mr Obama’s watch new attempts have been made to weigh evidence for different treatments. But the notion that evidence might be used to limit care remains heretical.

To an outsider, it might seem helpful to know which services are worthwhile. America, after all, spends 18% of its GDP on health, far more than other rich countries. About one-third of that spending is waste. But America has a unique distaste for evidence. Most other rich countries have a formal way to judge the efficacy of different treatments. Britain has the strictest system. There the National Institute for Health and Clinical Excellence (NICE) judges the worth of new drugs and procedures. If the agency favours a treatment, the National Health Service will pay for it. If the agency does not, patients must pay for it themselves. Such a system makes American politicians shudder.

Bad Pharma. By Ben Goldacre. Fourth Estate; 430 pages; £13.99. To be published in America in January by Faber and Faber; $28. Buy from Amazon.com, Amazon.co.uk

DOCTORS like to project an air of authority when making their clinical decisions. Patients like it too, for it is reassuring to think that one’s health is in the hands of an expert. It would be unsettling if, upon prescribing you a drug, your doctor admitted that the scientific research about what exactly the drug did, and how effective it was at doing it, was patchy and distorted, sometimes to the point where nobody has any real idea of what effects the drugs they are prescribing are likely to have on their patients.

But that is the reality described in “Bad Pharma”, Ben Goldacre’s new book. A British doctor and science writer, he made his name in 2008 with “Bad Science”, in which he filleted the credulous coverage given in the popular press to the claims of homeopaths, reiki therapists, Hopi ear-candlers and other purveyors of ceremonious placebos. Now he has taken aim at a much bigger and more important target: the $600-billion pharmaceutical industry that develops and produces the drugs prescribed by real doctors the world over.

The book is slightly technical, eminently readable, consistently shocking, occasionally hectoring and unapologetically polemical. “Medicine is broken,” it declares on its first page, and “the people you should have been able to trust to fix [its] problems have failed you.” Dr Goldacre describes the routine corruption of what is supposed to be an objective scientific process designed to assess whether new drugs work, whether they are better than drugs already on the market and whether their side effects are a price worth paying for any benefits they might convey. The result is that doctors, and the patients they treat, are hobbled by needless ignorance.

So, for instance, pharmaceutical companies bury clinical trials which show bad results for a drug and publish only those that show a benefit. The trials are often run on small numbers of unrepresentative patients, and the statistical analyses are massaged to give as rosy a picture as possible. Entire clinical trials are run not as trials at all, but as under-the-counter advertising campaigns designed to persuade doctors to prescribe a company’s drug.

The bad behaviour extends far beyond the industry itself. Drug regulators, who do get access to some of the hidden results, often guard them jealously, even from academic researchers, seeming to serve the interests of the firms whose products they are supposed to police. Medical journals frequently fail to perform basic checks on the papers they print, so all sorts of sharp practice goes uncorrected. Many published studies are not written by the academics whose names they bear, but by commercial ghostwriters paid by drug firms. Doctors are bombarded with advertising encouraging them to prescribe certain drugs.

The danger with a book like this is that it ends up lost in abstract discussion of difficult subjects. But Dr Goldacre illustrates his points with a plethora of real-world stories and examples. Some seem almost too breathtaking to be true—but every claim is referenced and backed up by links to research and primary documents. In scenes that could have come straight from a spy farce, the French journal Prescrire applied to Europe’s drug regulator for information on the diet drug rimonabant. The regulator sent back 68 pages in which virtually every sentence was blacked out.

And of course, the upshot of all this is anything but abstract: doctors are left ignorant about the drugs they are prescribing, and which will make their patients sick or get well, or even live or die. Statins, for instance, lower the risk of heart attacks, and are prescribed to millions of adults all over the world. But there are several different sorts of statin. Because there is little commercial advantage to be gained by comparing the efficacy of the different varieties, no studies have done so in a useful way.

Bereft of guidance, doctors must therefore prescribe specific statins on the basis of little more than hunches or personal prejudice. As Dr Goldacre points out, if one drug is even a shade more effective than its competitors, then thousands of people prescribed the inferior ones are dying needlessly every year for want of a bit of simple research. That is a scandal. Worse, the bias and distortions that brought it about are repeated across the entire medical industry. This is a book that deserves to be widely read, because anyone who does read it cannot help feeling both uncomfortable and angry.

On the BBC, Ruth Evans describes a widespread Japanese superstition about the relationship between blood-types and personality. Apparently, the modern junk-science belief originates with a crank called Masahiko Nomi who published a “a book in the 1970s” about it, and his son Toshitaka has continued the family tradition with more woo books and an “Institute of Blood Type Humanics.” However, Evans implies that the origin of this belief is the eugenics-grounded ideology of the Imperial militarist Japanese government of the 1930s, who “formed battle groups according to blood type.”

Studies in the 1950s found that when two psychiatrists evaluated the same patient, they gave the same DSM diagnosis only about 40 percent of the time. Rates of consistency have improved since then, but the diagnosis of many mental disorders remains, despite pretensions to the contrary, more art than science.

It’s true that people with substance abuse problems can “detox” when they get clean, but the kind of “detoxing” offered by stuff in the grocery store or pharmacy has no basis in science and is just a scammy way to scare you into opening your wallet (the companies that sell “detox” can’t even say what “toxins” they’re getting rid of).

Worst of all are the dietary supplements that make your poo into a kind of plastic in order to trick you into thinking that your colon has been “cleansed,” as well as potentially dangerous enemas, and foot-baths that do a simple chemistry trick to make the water turn brown as though some kind of gunk has been sucked out of the soles of your feet.

There’s no such thing as ‘detoxing’. In medical terms, it’s a nonsense. Diet and exercise is the only way to get healthy. But which of the latest fad regimes can really make a difference? We look at the facts

The 14 were not calling for unfettered poaching: they want to be allowed to use products from farmed animals. Bears have long been caged with tubes attached to their gall bladders to “milk” their bile. Rhinos and tigers are now also farmed: some 6,000 tigers, 50% more than survive in the wild, are on Chinese farms. China is said to have stocks of 100 tonnes of tiger bones against annual medical-industry demand of around 22 tonnes (about 1,000 tigers).

Why not allow the sale of farmed products, rendering poaching redundant? There is also pressure to allow the sale of poached material seized by governments. South Africa is to ask CITES, at its conference this September in Johannesburg, to permit the sale of some of its stocks of seized rhino horn. The snag: nothing suggests that legal trade cuts poaching at all. On the contrary, it makes it easier to launder illegal goods. It also destigmatises the consumption of endangered body parts, thus raising demand for them. And it can raise the value of the wild product, which is believed by many fans of Chinese medicine to be more potent.

Tiger-bone wine, rhino horn and the like are the platinum-label whiskies of the Asian wellness industry: pricey, prestigious and useful for lubricating business deals. Demand is driven not by medical professionals who nurture millennia-old traditions, but by the networks that feed supply—poachers, holders of stocks of banned items, farmers and their allies in some governments.

Mr Laidler, who has since disavowed alternative autism interventions including chelation and special diets, recalls the physical and financial strain of shuttling back and forth from treatments and travelling with suitcases full of special foods. When Mrs Laidler secretly took one of their sons off his supplement regimen and found no change in behaviour, he had an epiphany: what he had perceived as improvements due to treatment were really just natural fluctuations.

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Today alternative medicine is just as popular. A study by the Centres for Disease Control and Prevention in 2012 established that one-third of adults use some sort of alternative treatment, mostly in addition to conventional medicine. The annual bill for such “complementary” interventions is about $34 billion. Despite the fact that the great majority of alternative treatments are either unproven or known to be rubbish, the discipline has also become more intertwined with conventional medicine. A recent study showed that 42% of American hospitals provided some sort of alternative therapies, up from 27% in 2005. Georgetown University offers masters degrees in complementary medicine, and the University of Arizona trains its medical students in the practice.

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Sick people often seek help when they feel most ill. Like Mr Laidler, they may mistake the natural cycle of a condition for improvement caused by treatment. And while the web makes it easy for a layman researching crystal therapy (where a “healer” places small crystals at various points on patients’ bodies) to determine quickly that such a treatment has never been proved effective, it has also encouraged quacks. So long as they include disclaimers, anyone can slap up free websites offering treatments to help with baldness and pudginess, the flu and cancer. At best, people will waste money chasing such promises. At worst, they could get hurt.

In India the average consultation lasted three minutes, a quarter as long as in OECD countries. A third lasted less than a minute and involved no examination and just one question from the clinician: “What’s wrong with you?” The correct treatment was given in 30% of cases, and unnecessary or harmful treatment in 42%.

Patients fare little better in China. A team led by Sean Sylvia of Renmin University of China sent standardised patients to clinics in Shaanxi province. Health workers spent an average of 96 seconds with patients. They gave a correct diagnosis in just 26% of cases, and an outright wrong one in 41%. Inept treatment is not because providers are too busy. According to the World Bank, in India, Kenya, Senegal and Tanzania each one sees just eight to ten patients a day. Those in India spent just 40 minutes a day on average seeing patients.

A better explanation starts with the fact that many clinicians have received little training and do not know what they are doing. In India and China more medical training is (reassuringly) associated with making fewer mistakes. And a recent Kenyan study using standardised patients found that clinicians in Nairobi made “significantly better” diagnoses than Indian and Chinese ones, who had less training.

(In private, Mao confided to one of his doctors: “Even though I believe we should promote Chinese medicine, I personally do not believe in it.”)

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Mr Xi’s efforts may bring some benefits. To the extent that TCM promotes a healthy diet and way of life, it is to be lauded. TCM practitioners who also have skills in conventional medicine may be able to fill gaps in China’s woefully inadequate primary health-care system. But there are dangers, too. Devoting more resources to TCM could mean less money for health care that is based on science. Here TCM falls down. Most of its treatments are at best a placebo and at worst a harmful distraction from the task of curing people, or downright dangerous. In 2015 a Chinese pharmacologist, Tu Youyou, became the first scientist to win a Nobel prize for work carried out in China. She had isolated a chemical in TCM that could treat malaria. The Chinese government claimed this as evidence that TCM as a whole was effective. In fact, as the Nobel committee emphasised TCM provided only the inspiration for the research that led to her award. When a traditional medicine is proved to work, there is always an underlying medical mechanism.

The market in Bozhou is both a symbol of an extraordinary boom in TCM, and a consequence of it. The number of hospitals offering TCM in the country of its birth (either by itself or in combination with regular medicine) grew from roughly 2,500 in 2003 to 4,000 at the end of 2015. Since 2011 the number of licensed practitioners has increased almost 50% to 452,000. Around 60,000 TCM medicines have been approved by the government’s food and drug regulator. These account for almost a third of China’s pharmaceutical market, the world’s second largest. In 2015 patients made 910m visits to TCM hospitals and doctors, which, the government said, accounted for 16% of total medical care, up from 14% in 2011.

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Early in 2016 the government published a blueprint for developing TCM over the next 15 years. Traditional medicine, it said, should have equal status in law with modern medicine; it should also be regulated like other types. A “white paper” issued at the end of last year said TCM would play a big role in reforming the health-care system because of its relatively low cost.

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Its proponents respond that TCM can improve both public health and the health-care system. Traditional medicine relies on herbal and other natural remedies, not expensive diagnostic machines. According to the white paper, average inpatient expenses per visit at public TCM hospitals were 24% lower than at general public hospitals; outpatient expenses were 12% lower. If TCM is as effective as Western medicine—a big if—then it would appear to be an efficient means of improving health.

But evidence that TCM works is scanty. Clinical trials in scientific journals have reported some examples of effective TCM treatments, for example against migraines and obesity. They have found some cases where TCM works well in combination with Western medicine, for example, in treating schizophrenia. However, the overall record is poor.

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Far tighter controls on the use of animals and plants are needed. According to Meng Zhibin of the Institute of Zoology in Beijing, 22% of the 112 most commonly used natural ingredients for TCM are on various endangered-species lists. Some are from herbs that can be grown on farms, but some are from rare animals that are usually captured and smuggled into the country. Trade in pangolin, an anteater, is banned worldwide. But Wang Weiquan of the Chinese Medicine Association says smuggling continues because domestic pangolin farms are not big enough. TCM proponents do not seem to care. They worry about the future of traditional medicine itself. Wen Jianmin of the Wangjiang TCM hospital in Beijing says the ban on the use of some animals has already led to the extinction of some famous traditional remedies. “If we don’t protect TCM better, Chinese medicine will exist only in name,” he says.